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J Neurooncol (2010) 99:333–340

DOI 10.1007/s11060-010-0367-6

INVITED REVIEW

Modern meningioma imaging techniques


D. Saloner • A. Uzelac • S. Hetts • A. Martin •

W. Dillon

Received: 2 July 2010 / Accepted: 17 August 2010 / Published online: 1 September 2010
Ó The Author(s) 2010. This article is published with open access at Springerlink.com

Abstract Steady improvements in imaging modalities aspects of the tumor. Once a meningioma has been identified
have enabled a new realm of capabilities in the identifi- and surgery is planned, imaging plays an essential role when
cation and assessment of meningiomas. The cross-sectional embolization is performed utilizing X-ray fluoroscopy to
imaging modalities, MRI and CT, have improved in reso- reduce blood loss at subsequent surgery.
lution and fidelity. These modalites now provide not only
improved structural information but also insights into
functional behavior. MRI has, in particular, proven to have Computed tomography
powerful capabilities in evaluating meningiomas because
of the ability to assess soft tissue characteristics such as Although MRI is the imaging study of choice for evalua-
diffusion and vascular supply information, such as perfu- tion of suspected meningioma or in the context of known or
sion. Recent investigational advances have also been made highly suspected pathology, computed tomography (CT) is
using a combination of X-ray fluoroscopy for selective more widely available, is better suited for rapid screening
catheterization followed by MR perfusion measurement in urgent settings, and can be used when patients have MRI
performed with intra-arterial injection of contrast. Together exclusions (such as pacemakers). As such, many menin-
all these modalities provide the radiographer with powerful giomas are first encountered on CT scans obtained for
capbilities for evaluating meningiomas. different reasons. CT has a place in the diagnosis of
meningioma because it is superior in demonstrating the
Keywords Meningioma  MRI  CT  Angiography  effects of this neoplasm on adjacent bone, specifically
Perfusion  Imaging osseous destruction in atypical or malignant meningiomas
or hyperostosis associated with the benign meningiomas,
and is more sensitive in detecting psammomatous calcifi-
Introduction cations in the tumor (seen grossly in approximately 25% of
meningiomas). Benign meningiomas typically appear as
The detection and accurate diagnosis of meningiomas has rounded or elongated extraaxial masses that demonstrate a
been dramatically improved by the availability of modern broad attachment to the dura. On CT, they are usually
cross-sectional imaging methods, namely magnetic reso- isodense, but can occasionally be hyper dense or slightly
nance imaging (MRI) and multi-detector computed tomog- hypo dense compared to cerebrum.
raphy (MDCT). Not only do these modalities provide highly Their extraaxial nature is suggested by a sharp inter-
detailed information on the structure and composition of face with displaced brain parenchyma, the presence of a
meningiomas but also important insights into functional cerebrospinal fluid attenuation cleft and tumor intense
enhancement. Meningiomas exhibit homogeneous attenu-
ation prior and after administration of contrast material, but
D. Saloner (&)  A. Uzelac  S. Hetts  A. Martin  W. Dillon
can show some heterogeneity depending on the consistency
Department of Radiology and Biomedical Imaging, University
of California, San Francisco, CA, USA of tumor, i.e., the presence of calcium, fat, tumor necrosis.
e-mail: saloner@radmail.ucsf.edu Hyperostosis of adjacent skull is highly suggestive of

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Fig. 1 Dural based mass


(arrow in both figures) is
appreciated in the left middle
cranial fossa with associated
hyperostosis of the sphenoid
bone, squamosal temporal bone,
orbital roof demonstrated by CT
(a) and axial T2 MR sequence
performed for surgical
navigation (b). These findings
are most consistent with an en
plaque meningioma with
involvement and associated
hyperostosis of the underlying
bone. Note the white matter
vasogenic edema in the left
temporal lobe due to mass effect
(small arrow)

benign meningioma and is best demonstrated by CT,


windowed on bone algorithm, as cortical thickening and
hyper density (Fig. 1). Hyperostosis typically indicates
infiltration of bone by meningioma [1].

Magnetic resonance imaging

Common imaging features of meningiomas on MRI

Most meningiomas have features that are similar including


an extraaxial mass with signal intensity similar to cortex on
T1 and T2 MRI sequences, avid homogeneous enhance-
ment following administration of gadolinium contrast, and
an enhancing ‘‘dural tail’’ which reflects neoplastic dural
infiltration or reactive vascularity, or both, draining into the
adjacent dura. Low signal intensity within the tumor may
often be due to calcification or to vascular flow voids, a
distinction sometimes difficult to make. Meningiomas can Fig. 2 Large interhemispheric extra-axial mass consistent with a
parafalcine meningioma with a dominant left parafalcine component
be nearly spherical or elongated (en plaque), multiple, and
and a smaller right parafalcine component (arrow)
often take origin from a dural sinus, a feature important for
surgical planning. These tumors also tend not to respect the
dural boundary, which is a distinctive feature not typical of invasion causing vascular congestion [2]. The presence of
other neoplasms (Fig. 2). intra-axial edema is said to predict an increased potential
Although most benign meningiomas are innocuous from for recurrence [3, 4].
the standpoint of metastatic potential, they may result in
serious complications secondary to dural sinus invasion
(Fig. 3), (with or without thrombosis), narrowing and Advanced imaging
thrombosis of significant arterial structures, and compres-
sion of cranial nerves and other important neural structures. Nuclear medicine methods
Edema associated with meningioma is thought to be
vasogenic in origin, and probably related to tumor secretion There have been reports that radiolabeled agents, such as
111
of vascular endothelial growth factor (VGEF), rather than a In-octreotide, that have an affinity for somostatin recep-
result of direct mass effect on adjacent brain or venous tors can be useful in detecting and localizing meningiomas

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J Neurooncol (2010) 99:333–340 335

Fig. 3 Large right-sided transtentorial meningioma with growth into the right sigmoid (small arrow in c) demonstrated on post gadolinium axial
T1 (a) and post gadolinium coronal MR venogram (d). Hyperostosis of adjacent skull pointed by large arrow (a)

[5]. However, this ability is countered by the relative lack of a voxel is restricted there is greater magnetization coherence
specificity in differentiating meningiomas from other and that voxel will appear bright. This technique is referred
lesions such as high-grade glioma or pituitary adenomas, to as diffusion weighted imaging (DWI). Reduced water
among others. PET imaging is attractive for investigating diffusivity (Fig. 4a) has been correlated with more aggres-
the metabolic activity of tumors [6]. However, the role of sive tumor behavior and is sometimes seen with atypical/
PET imaging in the evaluation of meningiomas is compli- malignant meningiomas, high cellular density, and recur-
cated by the variable metabolic presentation in different rence [8].
meningioma types. In typical benign meningiomas, the The diffusion weighting in DWI acquisitions is encoded
usual metabolic marker F-18 fluorodeoxyglucose, presents on top of the usual T1 and T2 properties of the underlying
with isometabolism on PET imaging. Malignant meningio- sequence. It is possible to create images that are insensitive
mas may display hypermetabolism which confounds their to those underlying T1 and T2 values by performing
differentiation from other intracranial tumors [7]. In general, multiple DWI acquisitions and extracting from them a map
nuclear medicine techniques provide capabilities that are of the diffusion effect alone, referred to as an apparent
sensitive for meningiomas but that have relatively low diffusion coefficient (ADC) map. A decrease in ADC
specificity. values (Fig. 4b) at follow up of a benign meningioma
should raise suspicion for dedifferentiation to higher tumor
Diffusion MRI grade [9]. Although diffusion-weighted imaging provides
an added tool in the approach to defining meningioma
It is possible using MRI to sensitize the image appearance to grade a recent report [10] calls into question the predictive
the extent to which water can freely diffuse in any volume ability of DWI methods in grading meningiomas or iden-
element (voxel). When the motion of water molecules within tifying histological sub-types.

Fig. 4 Reduced diffusion is


seen within this left parafalcine
meningioma. First image
(a) demonstrate high signal on
the DWI, with corresponding
low signal on the ADC maps (b)

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Perfusion to dural-meningeal supply) usually predicts an aggressive


meningioma with a higher tendency of recurrence.
It is possible to perform MRI with acquisition times that The cerebral volume of peri tumoral edema was found
are short enough to capture the changes in signal intensity by Zhang et al. [11] to be elevated surrounding malignant
as a bolus of contrast material passes through the brain. meningiomas compared to the vasogenic edema associated
These methods, termed perfusion MRI, can provide useful with benign meningiomas, and likely related to angiogen-
information on the vascular supply of meningiomas, which esis/microvascular proliferation in the peri tumoral brain.
is only implied from conventional MRI. Typically, the
injection is performed at a rate and concentration that
causes a loss of signal secondary to perturbation of the Conventional angiography and endovascular
magnetic field by the contrast agent. The method used is an embolization
echo-planar contrast-enhanced T2* weighted sequence
rapidly performed prior, during, and after the bolus infu- Conventional angiography is most often performed for pre-
sion of gadolinium contrast material using an intravenous operative endovascular embolization and is intended to
injection. The curves reflect the permeability between minimize the blood loss intraoperatively. With the increase
intravascular and extravascular compartments, as well as use of preoperative embolization, the subsequent MRI
cerebral blood volume. The relative cerebral blood volume changes and treatment complications [12], i.e., hemorrhage
(rCBV) is measured within a tumor comparing to the and necrosis sometimes present a confusing imaging picture
contralateral normal white matter and can be displayed on for a radiologist who is unaware of the prior embolization
color maps [11]. Perfusion curves provide additional procedure. MRI changes that occur after embolization of
prognostic information by helping distinguish between meningiomas usually include a decrease in gadolinium
benign and atypical/malignant meningiomas. contrast enhancement (Fig. 7b), reduced diffusion of the
Benign meningiomas typically derive their blood supply devascularized segment of the tumor (Fig. 7c, d).
from the external carotid via dural branches. These vessels
do not contain a blood brain barrier and are thus quite
permeable to gadolinium, which is reflected by a curve Advanced MRI during endovascular embolization
with little or no return to baseline following infusion of meningiomas
(Fig. 5a, b).
As the meningioma enlarges, it may parasitize pial MR perfusion using intraarterial injections
branches from the brain parenchyma, which do contain a
blood brain barrier. The perfusion scans will show an As discussed above, MRI offers advantages over X-ray
elevated cerebral blood volume with intensities that return angiography in the evaluation of tissue physiology, includ-
to baseline signal levels, reflecting an intact blood-brain ing measurement of diffusion and perfusion characteristics
barrier of the internal carotid artery supply, as seen in that serve as proxies for tissue infarction and vascularity,
Fig. 6. A high volume of pial-cortical supply (as opposed respectively. In assessing the vascularity of meningiomas,

Fig. 5 MR perfusion of left


frontal meningioma
demonstrates significantly
elevated relative cerebral blood
volume (area under the curve is
large) (purple curve in b),
compared with contralateral
normal matter (green curve).
The less than 50% return to
baseline (b) is typical of the
lack of blood brain barrier of the
external carotid artery

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Fig. 6 Large ethmoid groove


meningioma (a) with perfusion
characteristics suggesting
internal carotid artery supply—
intact blood–brain barrier/no
permeable vessels. ROI placed
in the menignioma (1 in c) is
compared to normal white
matter. A large area under the
curve (d) represents elevated
cerebral blood volume

Fig. 7 Pre- (a) and post-embolization (b) T1 post gadolinium on features accompanying embolization can mislead the radiologist or
same patient demonstrates an initially homogeneously enhancing surgeon, if they are not provided the history of the embolization
meningioma with decreased enhancement, reduced diffusion (c) and procedure
low signal on the ADC map (d) in the embolized component. The

there is substantial interest in clearly defining which specific of intracranial meningiomas is performed to reduce tumor
arterial branch is providing blood supply to the specific vascularity and thus minimize operative blood loss but is not
regions of interest. For example, preoperative embolization possible if the internal carotid artery (ICA) is the only source

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of blood supply as embolic material delivered through the MRI suite in which a patient can be slid on a single bed
ICA would also obliterate normal brain tissue. between X-ray angiography and MRI intraprocedurally.
Conventional MR perfusion methods are performed That suite has been used to monitor the completeness of
with an intravenous injection into an arm vein. The contrast tumor embolization in 15 patients [13]. Via a standard
material is then transported back to the heart and ejected transfemoral arterial approach under X-ray guidance non-
into the arterial system. As such, intravenous MR perfusion braided 5 French (Fr) diameter diagnostic catheters (which
studies are non-selective and perfusion of a specific region have undergone extensive testing for MR safety [14]) are
of interest reflects supply from all arterial sources. Fur- placed in the external carotid artery (ECA) of subjects.
thermore, the temporal passage of the contrast bolus is Patients are then slid from X-ray to MR nd a baseline MR
substantially modulated by significant patient-specific perfusion study is performed by injecting dilute gadolinium
characteristic dynamics that have little to do with tissue contrast through the ECA catheter. The catheter is then
perfusion, such as recirculation times in the veins and the pulled back to the CCA and a similar intraarterial (IA)
lungs, mixing efficiency in the heart, and arterial tortuosity. perfusion study is performed. By subtracting the ECA
Selective intraarterial injections performed in an MR suite supply from the CCA supply, the ICA supply to the tumor
provide powerful new capabilities in evaluating meningi- can be determined without having to do a separate ICA
oma perfusion. The ability to investigate the impact of catheterization. Patients are then moved back to the X-ray
intraarterial procedures on the end organ is now available fluoroscopy suite for the embolization portion of the pro-
at a number of sites that have so-called XMR suites, an cedure. The intraarterial study can then be repeated post-
installation that contains both an X-ray fluoroscopy suite embolization (Fig. 8).
and an MRI scanner in the same room. Although it would The technique of endovascular meningioma emboliza-
not currently be recommended to perform catheterization tion is well established [15–18]. In brief, a microcatheter
solely for the purpose of determining perfusion character- (1.9–2.3 Fr) is placed through the 5 Fr catheter in the ECA
istics, intraarterial MR perfusion studies are possible when superselectively into the dural vessel supplying the tumor
conducted in the same session that the patient is already (usually the middle meningeal artery, a branch of the ECA)
undergoing catheterization for pre-surgical embolization. (Fig. 9). Microcatheter angiograms are performed to con-
Complete X-ray catheter cerebral angiography is per- firm that only tumor (and not normal critical structures
formed in the context of preoperative embolization and, such as the retina) is supplied by the catheterized vessel.
thus, fulfills a secondary goal of identifying all arterial Embolization is achieved by injection of 350–500 lm
supply to the tumor, whether embolized or not. X-ray diameter plastic particles (polyvinyl alcohol, PVA) until
angiography is able to qualitatively evaluate regional stasis is achieved in the tumor-supplying artery. The
capillary-level vascularity within the tumor as each sup- microcatheter is then cleared by saline injection and
plying artery is separately injected with iodinated contrast pushable platinum coils are often placed more proximally
material. in the feeding artery to achieve complete arterial occlusion.
At the University of California San Francisco, the XMR The microcatheter is removed, but the 5 Fr catheter
suite consists of a combined X-ray angiography and 1.5T remains in the ECA. The patient is then moved back into

Fig. 8 (a) Meningioma visualized on MRI prior to treatment. injection into the external carotid artery provides a map of Cerebral
(b) Intraarterial injection into the common carotid artery provides a Blood Volume related to supply from the ECA alone [note no
map of Cerebral Blood Volume related to supply from ICA and ECA perfusion of normal brain tissue is noted]. (d) Post-embolization
pre-embolization [note that normal brain tissue on the ipsilateral side intraarterial injection into the ECA displays a small residual supply
also reflects perfusion effects]. (c) Pre-embolization intraarterial from the ECA that was not obliterated at embolization

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likely to bleed intraoperatively when embolization is


incomplete. These techniques may also prove valuable in
monitoring the effects of new embolic agents, such as
liposomes carrying chemotherapeutics or anti-tumor anti-
bodies. As minimally invasive MRI of tumor physiology
improves and is validated against resected tumor histology,
its ability to monitor nonsurgical treatments for dural and
nondural brain neoplasms also comes closer to realization.

Conclusion

In summary, meningiomas have a typical but sometime


variable appearance on MR and CT. Modern imaging tools
can usually suggest the histological diagnosis, but usually
not the grade of tumor. Perfusion and diffusion imaging have
been useful tools for diagnosis and for suggestion of alter-
native histologies, as well as predicting aggressive histo-
logical features. Catheter angiography performed during
Fig. 9 Characteristic appearance at angiogram of a middle cranial
fossa meningioma with extensive arterial supply from a left middle preoperative embolization of meningioma is useful in elu-
meningeal artery cidating the feeding arteries of the meningioma. There are
now investigative studies that indicate that intraarterial MR
perfusion methods could be useful in better understanding
the MR scanner and selective IA perfusion studies are the perfusion characteristics of meningiomas, and could be
repeated with the 5 Fr catheter in the ECA and then pulled used in montoring the delivery of therapeutics.
back into the CCA. After this second set of IA perfusion
studies, the 5 Fr catheter is removed and the femoral Acknowledgment This work has been supported by grant
CA123840 from the National Institutes of Health.
arterial access site is closed.
The advanced MRI techniques that are used intrapro- Open Access This article is distributed under the terms of the
cedurally during the course of endovascular embolization Creative Commons Attribution Noncommercial License which per-
of meningiomas show promise for guiding both emboli- mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
zation and surgery [13]. Different IA perfusion techniques,
including T2* dynamic susceptibility contrast (DSC) and
T1 dynamic contrast enhanced (DCE), have been applied. References
As expected, T2* based techniques appear to be of limited
value in heavily calcified meningiomas, but T1 based 1. Pieper DR, Al-Mefty O, Hanada Y, Buechner D (1999) Hyper-
techniques may be of more use in such lesions. MR per- ostosis associated with meningioma of the cranial base: second-
fusion maps appear to be more sensitive in detecting ary changes or tumor invasion. Neurosurgery 44(4):742–746,
(discussion 746–747)
residual tumor vascularity as compared to qualitative 2. Pistolesi S, Fontanini G, Camacci T et al (2002) Meningioma-
analysis of X-ray angiographic images [13]. ECA perfusion associated brain oedema: the role of angiogenic factors and pial
usually correlates well with dural tumor supply on X-ray blood supply. J Neurooncol 60(2):159–164
angiography; ICA perfusion (CCA minus ECA) similarly 3. Vignes JR, Sesay M, Rezajooi K, Gimbert E, Liguoro D (2008)
Peritumoral edema and prognosis in intracranial meningioma
usually correlates with pial supply. Diffusion-weighted surgery. J Clin Neurosci 15(7):764–768
imaging (DWI) is also being applied to evaluate for 4. Simis A, Pires de Aguiar PH, Leite CC, Santana PA Jr, Rosem-
embolization-induced tumor infarction (or unanticipated berg S, Teixeira MJ (2008) Peritumoral brain edema in benign
ischemia of non-tumor tissue). Correlations between MR meningiomas: correlation with clinical, radiologic, and surgical
factors and possible role on recurrence. Surg Neurol
findings and regional histology of resected tumors are 70(5):471–477
performed to validate MR findings but study numbers are 5. Krenning EP, Breeman WA, Kooij PPM et al (1989) Localisation
not yet sufficient to define which combination of advanced of endocrine-related tumours with radioiodinated analogs of
MR techniques is optimal. somatostatin. Lancet 4:242–244
6. Chang AS, Ross JS (2008) Diagnostic neuroradiology: CT, MRI,
It is hoped that IA perfusion techniques will provide fMRI, MRS, PET, and Octreotide SPECT. In: Lee JH (ed)
better preoperative insight into tumor vascularity, allowing Meningiomas, diagnosis, treatment and outcome. Springer, Hei-
surgeons to better anticipate which areas of tumor are still delberg, 55–65

123
340 J Neurooncol (2010) 99:333–340

7. Lippitz B, Cremerius U, Mayfrank L et al (1996) PET-study of 13. Martin AJ, Cha S, Higashida RT, Cullen SP, Halbach V, Dowd
intra-cranial meningiomas: correlation with histopathology, cel- CF, McDermott MW, Saloner DA (2007) Assessment of
lularity and proliferation rate. Acta Neuroschir Suppl 65:108–111 meningioma vasculature and the effects of embolization with
8. Nagar VA, Ye JR, Ng WH et al (2008) Diffusion-weighted MRI: intra-arterial MR perfusion imaging. Am J Neuro Radiol 28:
diagnosing atypical or malignant meningiomas and detecting 196–205
tumor dedifferentiation. AJNR Am J Neuroradiol 29(6): 14. Martin AJ, Baek B, Acevedo-Bolton G, Higashida R, Comstock
1147–1152 J, Saloner D (2009) MRI during endovascular procedures: an
9. Hakyemez B, Yildirim N, Gokalp G, Erdogan C, Parlak M (2006) evaluation of the potential for catheter heating. Magn Reson Med
The contribution of diffusion-weighted MRI to distinguishing 61(1):45–53
typical from atypical meningiomas. Neuroradiology 48(8): 15. Hieshima GB, Everhart FR, Mehringer CM et al (1980) Preop-
513–520 erative embolization of meningiomas. Surg Neurol 14:119–127
10. Santelli L, Ramondo G, Della Puppa A, Ermani M, Scienza R, 16. Latchaw RE (1993) Preoperative intracranial meningioma
d’Avella D, Manara R (2010) Diffusion-weighted imaging does embolization: technical considerations affecting the risk-to-ben-
not predict histological grading in meningiomas. Acta Neurochir efit ratio. AJNR Am J Neuroradiol 14:583–586
(Wien) 152(8):1315–1319 17. Dean BL, Flom RA, Wallace RC et al (1994) Efficacy of endo-
11. Zhang H, Rödiger L, Shen T (2008) Perfusion MRI for differ- vascular treatment of meningiomas: evaluation with matched
entiation of benign, malignant meningiomas. Neuroradiology samples. AJNR Am J Neuroradiol 15:1675–1680
50(6):525–530 18. Chun JY, McDermott MW, Lamborn KR et al (2002) Delayed
12. Carli DF, Sluzewski M, Beute GN, van Rooij WJ (2010) Com- surgical resection reduces intraoperative blood loss for embolized
plications of particle embolization of meningiomas: frequency, meningiomas. Neurosurgery 50:1231–1235 discussion 1235–1237
Risk Factors, and Outcome. AJNR Am J Neuroradiol 31:152–154

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